Prospective Evaluation of Antibiotic Management in Ureteral Stent and Nephrostomy Interventions

Urologia Internationalis ◽

10.1159/000517546 ◽

2021 ◽

pp. 1-8

Author(s):

Niklas Westhoff ◽

Alexey Anokhin ◽

Paul Patroi ◽

Manuel Neuberger ◽

Fabian Siegel ◽

...

Keyword(s):

Antibiotic Treatment ◽

Asymptomatic Bacteriuria ◽

Infectious Complications ◽

Ureteral Stent ◽

Multivariable Logistic Regression Model ◽

Acute Cystitis ◽

Asymptomatic Patients ◽

Antibiotic Management ◽

Before And After ◽

Comparative Group

Introduction: Screening for and treating asymptomatic bacteriuria (ABU) or administering antibiotic prophylaxis is recommended during ureteral stent and nephrostomy interventions. This study investigates the frequency of postinterventional infectious complications to gain insight into the need for antibiotics. Methods: Between September 2016 and June 2019, 168 insertions/exchanges of ureteral stents or nephrostomies were recorded in a prospective multicenter study. Patients without a symptomatic UTI did not receive antibiotic treatment/prophylaxis. Asymptomatic patients in whom their urologist already administered an antibiotic treatment served as a comparative group. Follow-up included postinterventional complications within 30 days. Symptoms were assessed by the Acute Cystitis Symptom Score (ACSS) before and after the intervention. Predictors of increasing postinterventional symptoms were analyzed by a multivariable logistic regression model. Results: One hundred forty-five interventions were eligible. One hundred twenty-two (84.1%) interventions were performed without antibiotic treatment. Preinterventional ABU was detected in 54.4% and sterile urine in 22.8% (22.8% without culture). Postinterventional infectious complications did not differ between patients with versus without antibiotics. Transurethral interventions aggravate symptoms (p = 0.034) but do not increase infectious complications compared to percutaneous interventions. Patients without diabetes mellitus are at higher risk for increasing symptoms. Conclusion: Results indicate that peri-interventional antibiotic treatment may be omitted in patients without symptomatic UTI. Symptoms must be differentiated between infectious and procedure-associated origins.

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Real-World Experience of the One-Year Efficacy of Rifaximin Add-On to Lactulose Is Superior to Lactulose Alone in Patients with Cirrhosis Complicated with Recurrent Hepatic Encephalopathy in Taiwan

Journal of Personalized Medicine ◽

10.3390/jpm11060478 ◽

2021 ◽

Vol 11 (6) ◽

pp. 478

Author(s):

Ching Chang ◽

Chien-Hao Huang ◽

Hsiao-Jung Tseng ◽

Fang-Chen Yang ◽

Rong-Nan Chien

Keyword(s):

Hepatic Encephalopathy ◽

Real World ◽

Ammonia Level ◽

Decompensated Cirrhosis ◽

Control Group ◽

Multivariable Logistic Regression Model ◽

Before And After ◽

One Year ◽

The One ◽

Serum Ammonia

Background: Hepatic encephalopathy (HE), a neuropsychiatric complication of decompensated cirrhosis, is associated with high mortality and high risk of recurrence. Rifaximin add-on to lactulose for 3 to 6 months is recommended for the prevention of recurrent episodes of HE after the second episode. However, whether the combination for more than 6 months is superior to lactulose alone in the maintenance of HE remission is less evident. Therefore, the aim of this study is to evaluate the one-year efficacy of rifaximin add-on to lactulose for the maintenance of HE remission in Taiwan. Methods: We conducted a real-world single-center retrospective cohort study to compare the long-term efficacy of rifaximin add-on to lactulose (group R + L) versus lactulose alone (group L, control group). Furthermore, the treatment efficacy before and after rifaximin add-on to lactulose was also analyzed. The primary endpoint of our study was time to first HE recurrence (Conn score ≥ 2). All patients were followed up every three months until death, and censored at one year if still alive. Results and Conclusions: 12 patients were enrolled in group R + L. Another 31 patients were stratified into group L. Sex, comorbidity, ammonia level, and ascites grade were matched while age, HE grade, and model for end-stage liver disease (MELD) score were adjusted in the multivariable logistic regression model. Compared with group L, significant improvement in the maintenance of HE remission and decreased episodes and days of HE-related hospitalizations were demonstrated in group R + L. The serum ammonia levels were significantly lower at the 3rd and 6th month in group 1. Concerning changes before and after rifaximin add-on in group R + L, mini-mental status examination (MMSE), episodes of hospitalization, and variceal bleeding also improved at 6 and 12 months. Days of hospitalization, serum ammonia levels also improved at 6th month. Except for concern over price, no patients discontinued rifaximin due to adverse events or complications. The above results provide evidence for the one-year use of rifaximin add-on to lactulose in reducing HE recurrence and HE-related hospitalization for patients with decompensated cirrhosis.

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10-Year Trends in Urine Testing and Treatment in Patients with Spinal Cord Injury: An Opportunity for Targeted Stewardship

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.586 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s90-s90

Author(s):

Alison Nelson ◽

Kalpana Gupta ◽

Judith Strymish ◽

Maura Nee ◽

Katherine Linsenmeyer

Keyword(s):

Spinal Cord ◽

Spinal Cord Injury ◽

Antibiotic Treatment ◽

Urine Culture ◽

Asymptomatic Bacteriuria ◽

Routine Screening ◽

Organizational Level ◽

Cord Injury ◽

Urine Testing ◽

Over Time

Background: Guidelines regarding asymptomatic bacteriuria (ASB) have consistently recommended against screening and treatment in most circumstances. However, screening of patients with spinal cord injury (SCI) is common practice and in some cases is a formal protocol at the organizational level. A previous study found that more than one-third of patients with ASB detected on routine screening cultures performed at annual visits in 2012 received antibiotics. However, the role of antibiotic stewardship has become more prominent over the last decade. We hypothesized that diagnostic and therapeutic stewardship efforts may be impacting the practice of annual urine-culture screening for SCI patients. We evaluated urine culture screening and treatment rates over a 10-year period. Methods: Patients with SCI seen in the VA Boston HCS for an annual exam in 2018 were eligible for inclusion and formed the baseline cohort for this study. Annual visits for the cohort over a 10-year period (January 1, 2009–December 31, 2018) were included in the analysis. Electronic data collection and manual chart review were utilized to capture outcomes of interest including urine culture, antibiotic prescriptions and indication within 15 days, and documentation of urinary or infectious symptoms. The main outcomes were (1) rate of urine cultures performed ±3 days of the visit, (2) rate of antibiotic treatment in asymptomatic patients, and (3) trend over time of urine culturing and treating. The χ2 test for trend was used to compare rates over time. Results: In total, 1,962 annual visits were made by the 344 unique patients over the 10-year period and were available for analysis. Among these, 639 (32.6%) visits had a urine culture performed within 3 days. The proportion of visits with a collected culture decreased from (109 of 127) 85.8% of visits in 2009 to (65 of 338) 19.2% of visits in 2018, P ≤ .001 (Fig. 1). In the treatment analysis, 39 visits were excluded for active symptoms, concern for uncontrolled infection, or prophylaxis as antibiotic indication. Among 600 remaining screening cultures, 328 had a bacterial pathogen or >100,000 mixed colonies consistent with ASB. Overall, 51 patients (17%) received antimicrobials. The rate of antibiotic treatment for ASB did not significantly decrease over time pP = 0.79 (Fig. 2). Conclusions: Over a 10-year period of annual SCI visits, the proportion of visits with a urine culture performed as routine screening significantly and consistently decreased. However, the rate of treatment for positive urine cultures remained consistent. These data support targeted diagnostic stewardship in this population to reduce unnecessary antibiotic use.Funding: NoneDisclosures: None

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Assessment of Testing and Treatment of Asymptomatic Bacteriuria Initiated in the Emergency Department

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa537 ◽

2020 ◽

Vol 7 (12) ◽

Author(s):

Lindsay A Petty ◽

Valerie M Vaughn ◽

Scott A Flanders ◽

Twisha Patel ◽

Anurag N Malani ◽

...

Keyword(s):

Emergency Department ◽

Antibiotic Treatment ◽

Asymptomatic Bacteriuria ◽

Antibiotic Use ◽

Altered Mental Status ◽

Estimating Equation ◽

Hospitalized Patients ◽

Clostridioides Difficile ◽

Cord Injury ◽

Clostridioides Difficile Infection

Abstract Background Reducing antibiotic use in patients with asymptomatic bacteriuria (ASB) has been inpatient focused. However, testing and treatment is often started in the emergency department (ED). Thus, for hospitalized patients with ASB, we sought to identify patterns of testing and treatment initiated by emergency medicine (EM) clinicians and the association of treatment with outcomes. Methods We conducted a 43-hospital, cohort study of adults admitted through the ED with ASB (February 2018–February 2020). Using generalized estimating equation models, we assessed for (1) factors associated with antibiotic treatment by EM clinicians and, after inverse probability of treatment weighting, (2) the effect of treatment on outcomes. Results Of 2461 patients with ASB, 74.4% (N = 1830) received antibiotics. The EM clinicians ordered urine cultures in 80.0% (N = 1970) of patients and initiated treatment in 68.5% (1253 of 1830). Predictors of EM clinician treatment of ASB versus no treatment included dementia, spinal cord injury, incontinence, urinary catheter, altered mental status, leukocytosis, and abnormal urinalysis. Once initiated by EM clinicians, 79% (993 of 1253) of patients remained on antibiotics for at least 3 days. Antibiotic treatment was associated with a longer length of hospitalization (mean 5.1 vs 4.2 days; relative risk = 1.16; 95% confidence interval, 1.08–1.23) and Clostridioides difficile infection (CDI) (0.9% [N = 11] vs 0% [N = 0]; P = .02). Conclusions Among hospitalized patients ultimately diagnosed with ASB, EM clinicians commonly initiated testing and treatment; most antibiotics were continued by inpatient clinicians. Antibiotic treatment was not associated with improved outcomes, whereas it was associated with prolonged hospitalization and CDI. For best impact, stewardship interventions must expand to the ED.

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Urine Cultures among Hospitalized Veterans: Casting Too Broad a Net?

Infection Control and Hospital Epidemiology ◽

10.1086/675829 ◽

2014 ◽

Vol 35 (5) ◽

pp. 574-576 ◽

Cited By ~ 8

Author(s):

Dimitri M. Drekonja ◽

Christina Gnadt ◽

Michael A. Kuskowski ◽

James R. Johnson

Keyword(s):

Asymptomatic Bacteriuria ◽

Clinical Manifestations ◽

Antimicrobial Treatment ◽

Antimicrobial Use ◽

High Count ◽

Asymptomatic Patients

Since detection of asymptomatic bacteriuria among inpatients often leads to inappropriate antimicrobial treatment, we studied why urine cultures were ordered and correlates of treatment. Most cultures were obtained from patients without urinary complaints and a minority from asymptomatic patients. High-count bacteriuria, not clinical manifestations, appeared to trigger most antimicrobial use.

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Catheterization Does Not Improve Course of Disease in Female Patients with Acute Cystitis or Pyelonephritis: Retrospective Analysis of >300 In-Hospital Treated Patients

Urologia Internationalis ◽

10.1159/000518066 ◽

2021 ◽

pp. 1-9

Author(s):

Mike Wenzel ◽

Benedikt Hoeh ◽

Konstatin Goeldner ◽

Felix Preisser ◽

Christoph Würnschimmel ◽

...

Keyword(s):

Antibiotic Treatment ◽

University Hospital ◽

White Blood Count ◽

Hospital Treatment ◽

Acute Cystitis ◽

Logistic Regression Models ◽

Female Patients ◽

Reactive Protein ◽

Catheter Group ◽

Multivariable Analyses

Purpose: Females with in-hospital treatment for acute cystitis (AC) or pyelonephritis may benefit from catheterization at admission. Methods: All female patients with AC or pyelonephritis requiring in-hospital treatment at University Hospital Frankfurt (2004–2019) were retrospectively analyzed. Logistic regression models were used to predict the catheter value. Results: Of 310 female patients, 40% harbored AC versus 60% pyelonephritis, of whom 62% and 74% received a catheter at admission: C-reactive protein (CRP) and white blood count (WBC) were significantly elevated in AC and pyelonephritis catheter versus no catheter patients (both p < 0.05). Time to CRP and WBC nadir did not differ between the AC catheter versus no catheter group (both p > 0.05). Conversely, time to CRP nadir was prolonged in pyelonephritis catheter patients. AC and pyelonephritis catheter patients exhibited a prolonged antibiotic treatment and length of stay (LOS, both p < 0.05). In multivariable analyses, CRP >5 ng/mL was a predictor for receiving a catheter in all patients. In AC, a positive urine culture and fever predicted, respectively, prolonged LOS or antibiotic treatment (all p < 0.05). Conclusion: Risk factors exist with regard to receiving a catheter and prolonged antibiotic treatment or LOS in females with AC or pyelonephritis. A catheter may not accelerate recovery or WBC nadir.

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Prevention and treatment of non-complicated infections of the lower urinary tract in pregnant women

Russian Journal of Woman and Child Health ◽

10.32364/2618-8430-2021-4-2-119-123 ◽

2021 ◽

Vol 4 (2) ◽

pp. 119-123

Author(s):

N.A. Nashivochnikova ◽

◽

V.N. Krupin ◽

V.E. Leanovich ◽

◽

...

Keyword(s):

Urinary Tract ◽

Pregnant Women ◽

Treatment Efficacy ◽

Asymptomatic Bacteriuria ◽

Control Group ◽

Chronic Cystitis ◽

Acute Cystitis ◽

Total Treatment ◽

Group 2 ◽

Group 1

Aim: to assess the efficacy of biologically active additive Cystenium II as a component of combined antimicrobial treatment of acute cystitis or exacerbation of chronic cystitis and asymptomatic bacteriuria (ASB) in pregnant women. Patients and Methods: 65 pregnant women with urinary tract infections were enrolled. Group 1 included 22 women with acute cystitis or exacerbation of chronic cystitis and group 2 included 20 women with ASB. These women received standard antimicrobial therapy (fosfomycin trometamol 3 g) and Cystenium II (1 tablet twice daily with food for 14 days). The control group included 23 women with acute cystitis or exacerbation of chronic cystitis or ASB who received standard antimicrobial therapy only. Treatment results were evaluated after 14 days and 2 months. Results: complete resolution of cystitis occurred on days 2 and 3 in group 1 and days 4 and 5 in group 2. Eradication of causative agent as demonstrated by inoculation of urine samples after 14 days was reported in 77.3% of women in group 1, 70% of women in group 2, and 61% of women in group 3. Total treatment efficacy in group 1 was 81.9%, i.e., exacerbations of chronic cystitis were diagnosed in 3 women (13.6%), acute pyelonephritis in 1 woman (4.5%). Total treatment efficacy in group 2 was 90%, i.e., recurrence of ASB was diagnosed in 2 women (10%). Meanwhile, treatment efficacy in the control group was 56.5%, i.e., clinical exacerbation of chronic cystitis was diagnosed in 6 women (26%). Moreover, in 4 women (17.4%), the disease was complicated by acute pyelonephritis. Conclusions: Cystenium II for acute cystitis or exacerbation of chronic cystitis and ASB in pregnant women improves treatment success and also maintains the effect. KEYWORDS: cystitis, asymptomatic bacteriuria, pregnancy, treatment, cranberry, prevention of recurrences. FOR CITATION: Nashivochnikova N.A., Krupin V.N., Leanovich V.E. Prevention and treatment of non-complicated infections of the lower urinary tract in pregnant women. Russian Journal of Woman and Child Health. 2021;4(2):119–123. DOI: 10.32364/2618-8430- 2021-4-2-119-123.

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1437. Safety and Effectiveness of a Laboratory Intervention to Reduce Antibiotic Consumption in Patients with Asymptomatic Bacteriuria

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.1301 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S524-S525

Author(s):

Mohammad Mozafarihashjin ◽

Lorraine Maze Dit Mieusement ◽

Allison McGeer ◽

Liz McCreight ◽

Liz Van Horne ◽

...

Keyword(s):

Asymptomatic Bacteriuria ◽

Systemic Infection ◽

Antibiotic Consumption ◽

Serious Adverse Events ◽

Asymptomatic Patients ◽

Urinary Tract Symptoms ◽

Specimen Processing ◽

Medical Wards ◽

Long Term Impact

Abstract Background Antibiotic (AB) therapy for asymptomatic bacteriuria (ASB) persists despite evidence of lack of benefit. In 2012, our hospital piloted an intervention to stop routinely reporting positive midstream urine (MSU) from inpatients since the majority of patients were asymptomatic. Following the pilot, we moved to rejecting all MSU unless a telephone request was received. We undertook the present study to establish the safety and assess the long-term impact of this change. Methods From November 2013 to April 2019, when MSU were received from surgical wards (two surgical wards added in May 2015) and medical wards (from August 2017) in our hospital, a message was posted noting that ASB should not be treated and a call to the lab was required to initiate specimen processing. Patients were interviewed, and charts were reviewed within 24h of specimen receipt and 4d later to identify urinary tract symptoms/infection (UTS/UTI) and systemic infection. Primary outcome was serious adverse events (AEs). Secondary outcomes were: rate of MSU submitted, impact on lab workload, AB use. Results 1,678 episodes with submitted MSU were included; 995/1,678 (60%) MSU cultures were not processed. Of 683 processed, 482 (71%) were negative. 1,111/1,678 (66%) patients were asymptomatic when MSU was ordered. 1,393/1,678 (83%) had negative culture (N = 482) or completed d4 follow-up (N = 911). No symptomatic UTI/sepsis/systemic infection occurred; the only AE identified were 4 patients with prolonged UTS which might have been prevented by MSU processing (4/911; 0.4% patients with AE). Rates of MSU submitted remained stable at 12 per 1,000 patient-days, P = 0.59 (Figure 1). Proportion of processed MSU decreased from 16/22, 73% in 2013 to 67/137, 49% in 2019 (Figure 2; P = 0.002). Overall, microbiology workload decreased by 5 person-days/year (fewer MSU processed, but staff needed to respond to telephone calls). 275/1,678 (16%) patients received AB for presumed UTI; 221 (80%) treated empirically, 54 (20%) in response to positive MSU. Of 69 patients with ASB whose MSU was processed and positive, 32 (46%) were prescribed antibiotics. Assuming that 21% of rejected MSU from asymptomatic patients would have been positive, AB therapy for ASB was avoided in 66 patients. Conclusion Rejecting MSU specimens does not result in harm, and reduces lab workload and AB therapy for ASB. Disclosures All authors: No reported disclosures.

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Assessment of Reflex Urine Culture Criteria Changes and its Impact on Treatment of Asymptomatic Bacteriuria

Open Forum Infectious Diseases ◽

10.1093/ofid/ofx163.829 ◽

2017 ◽

Vol 4 (suppl_1) ◽

pp. S346-S346 ◽

Cited By ~ 1

Author(s):

Kirre Wold ◽

Jeff Brock ◽

Kelly Percival ◽

Lindsey Rearigh ◽

Lucas Vocelka ◽

...

Keyword(s):

Asymptomatic Bacteriuria ◽

Signs And Symptoms ◽

Hospital Data ◽

Post Intervention ◽

Number Of Patients ◽

Positive Urine ◽

Before And After ◽

Implementation Period ◽

Inappropriate Antibiotics ◽

The Impact

Abstract Background Asymptomatic bacteriuria (ASB) is a common clinical condition identified by the presence of bacteria in the urine of a patient without signs and symptoms of a urinary tract infection (UTI). Treatment of ASB leads to unnecessary antimicrobial use and can cause more harm than benefit in many patients. This study is to determine the impact of more stringent criteria for urinalysis with culture if indicated (UAC), implemented in September 2016, on the treatment of asymptomatic bacteriuria. Methods A pre-post descriptive study of patients was conducted with an order placed for UAC in the Emergency Department (ED) or hospital. Data was collected retrospectively via chart reviews. The data on ASB patients from November 2015 to April 2016 was compared with the post-implementation period October 2016 to January 2017. The number of UAC orders and cultures were averaged for 6 months pre and post implementation of the criteria change. Results A total of 580 patient charts were assessed post-implementation of the UAC criteria change. A majority of the orders originated from the ED, (N = 430, 72.8%). ASB was treated inappropriately at a rate of 60.4% (N = 64/106) pre-implementation and a rate of 65% (N = 41/63) post implementation, P = 0.542. The total number of UAC ordered before and after implementation did not change, (N = 2852 pre-intervention vs N = 2825 post-intervention, P = 0.744), as seen in Figure 1. However, the number of reflexed urine cultures did significantly decrease post criteria change,  (N = 1056 pre-intervention vs. N = 603 post-intervention, P < 0.0001). In addition, the number of positive urine cultures also significantly decreased, (N = 378 pre-intervention vs. N = 289 post-intervention, P = 0.0447). The impact the criteria change had on patient care is the number of potential antibiotic courses saved by reflexing fewer urine cultures off the UAC. Based on the decrease in positive urine cultures, it is estimated 702 courses of inappropriate antibiotics for ASB could be saved per year (59/month). Conclusion More stringent criteria for reflex urine cultures significantly decreases the number of urine cultures performed, therefore decreasing the number of patients treated with ASB. Additional stewardship measures are necessary to reduce the treatment of ASB for patients who have cultures performed. Disclosures All authors: No reported disclosures.

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LO15: Treatment of asymptomatic bacteriuria in elderly patients with delirium: a systematic review

CJEM ◽

10.1017/cem.2018.77 ◽

2018 ◽

Vol 20 (S1) ◽

pp. S11-S12

Author(s):

A. Suleman ◽

J. Krakovsky ◽

P. Joo

Keyword(s):

Systematic Review ◽

Elderly Patients ◽

Antibiotic Treatment ◽

Full Text ◽

Primary Outcome ◽

Asymptomatic Bacteriuria ◽

Length Of Hospital Stay ◽

Female Gender ◽

Cochrane Library ◽

Full Text Review

Introduction: It is typical to look for UTI in delirious elderly patients, despite a high prevalence of asymptomatic bacteriuria (ASB) in this population. A common presentation of infection is delirium, which often has a non-specific and multifactorial etiology. Therefore, when bacteriuria is present with delirium in the absence of urinary symptoms, physicians prescribe antibiotics for the suspected UTI-induced delirium. We set to determine whether antibiotic treatment in the elderly presenting with delirium in the presence of ASB resulted in resolution of delirium. Methods: Literature searches were performed in MEDLINE, EMBASE, CINAHL and Cochrane Library. Abstracts were independently reviewed by two authors for decision to include for full-text review. Inclusion criteria included female gender, >65 years of age, presenting in an acute care setting with delirium and ASB. The primary outcome was resolution of delirium. The secondary outcomes were mortality, frequency of side effects from antibiotics, length of hospital stay and readmission for delirium. Results: 930 abstracts published from 1946-2017 were screened, and 42 were included for full text review. No studies were eligible for inclusion in the systematic review, as none addressed the primary outcome. One study addressed the outcomes of poor functional recovery after delirium and the rate of improvement of delirium symptoms after presentation of delirium with ASB. Conclusion: Even though current guidelines recommend against treatment of ASB, no guideline states whether ASB should be treated in elderly patients with delirium. Little evidence exists to elucidate whether treating delirious patients with ASB results in improvement in outcomes. Future studies should focus on demonstrating the relationship between resolution of delirium with antibiotic treatment. This will clarify whether delirium is a true symptom of ASB and whether treatment results in faster resolution of delirium.

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